Shoulder; dislocation; instability; skeletal immaturity; arthroscopic Bankart repair; outcomes Non-operative management of traumatic shoulder instability in children has a recurrence rate of up to 100%. Short-term outcomes of surgery in adults results has a quoted recurrence rates of around 10%. The aim of this study was to examine the surgical outcomes of adolescent patients (aged 13 to 18 years) undergoing arthroscopic stabilisation for shoulder instability.Keywords
Introduction
A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below knee or above knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. Twenty-six children (33 feet) were entered into the trial, with a mean age of 17 days (range 1–40) in the above knee and 11 days (range 5–20) in the below knee group. Because of six failures in the below knee group (38%), the trial was stopped early for ethical reasons. Failure rate was significantly higher in the below-knee group (P 0.039). The median treatment times of six weeks in the below knee and four weeks in the above knee group differed significantly (P 0.01).Statement of purpose:
Methods and Results:
Congenital vertical talus (CVT) is a rare deformity of the foot. It has been historically treated with extensive soft tissue releases with significant associated complications. Recently, reverse Ponseti-type casting followed by minimally invasive or percutaneous reduction and fixation has been described with excellent results in separate cohorts of either idiopathic or teratologic cases of CVT. There are currently no studies that compare the outcomes between the two types. We present a prospective cohort of 13 patients (21 feet) in which this technique has been used in both idiopathic and teratologic associated cases of CVT. Clinical, radiographic and parent-reported outcomes were obtained at a mean follow up of 36 months (range 8–57). Clinical and radiographic scoring was according to the system of Adelaar and parent-reported outcomes were assessed using the POSNA paediatric outcomes data collection instrument (PODCI).Background
Methods
To assess the success rate of closed reduction after failing Pavlik harness for treatment of DDH. It was a retrospective review of prospectively collected data. Patient's notes/computerised records were reviewed. Radiological investigations were also reviewed. Microsoft excel used for descriptive stats.Aims:
Methods:
Femoral head deformity can be a devastating outcome in a small percentage of patients with Perthes' disease. Deformities usually start during the fragmentation stage. In this study, we aimed to determine the effects of Vitamin D deficiency on the natural history of Perthes' disease. Patients with Perthes' disease and Vitamin D deficiency presenting to our unit in the last 3 years were identified. All X-rays were reviewed retrospectively to determine the duration of the fragmentation and ossification stages. Treatment methods were obtained from the notes. Late presenters (i.e. after fragmentation stage) were excluded. In our unit, Vitamin D deficiency is diagnosed if levels <72 nmol/L. Fifteen patients (17 hips) with Perthes' disease were found to be Vitamin D deficient. Levels ranged from (18–71 nmol/L). The mean length of the fragmentation stage was 15.7 months which is significantly higher than quoted literature figures (8 months). Ossification stage duration was 18.8 months which was comparable to quoted figures. However, patients with severe Vitamin D deficiency (< 52 nmol/L) were found to have longer ossification stage (20.6 months) compared with patients with mild deficiency (52–72 nmol/L) (16.4 months). Seven out of 16 patients (44%) required surgical containment which is significantly higher than the usually low rates of surgical intervention. The critical fragmentation stage in Vitamin D deficiency is significantly longer putting the femoral head at higher risk of deformity and extrusion. This leads to higher rates of surgical containment. Also the severity of Vitamin D deficiency might be an important determinant of the period of time required for ossification and healing. Vitamin D level is an important prognostic factor and must be measured in all patients with Perthes' disease. Prescribing Vitamin D supplements is advisable in this group of patients. However, the effects of these supplements on the course of the disease requires further research. Level of evidence: III
Audit of the outcome of subcapital osteotomy for a series of cases of severe unstable slipped capital femoral epiphysis. 57 cases of unstable severe slipped capital femoral epiphysis were operated on by a single surgeon between 2000 and 2011. The procedure was performed through the anterior abductor sparing approach. Patients have been followed up prospectively and the results are presented at average follow up is 6.4 years with a minimum of 18 month follow to include all risks of avn.Aim:
Method:
Our goal was to evaluate the use of Ponseti’s
method, with minor adaptations, in the treatment of idiopathic clubfeet
presenting in children between five and ten years of age. A retrospective
review was performed in 36 children (55 feet) with a mean age of
7.4 years (5 to 10), supplemented by digital images and video recordings
of gait. There were 19 males and 17 females. The mean follow-up
was 31.5 months (24 to 40). The mean number of casts was 9.5 (6
to 11), and all children required surgery, including a percutaneous
tenotomy or open tendo Achillis lengthening (49%), posterior release
(34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue
release combined with an osteotomy (2%). The mean dorsiflexion of
the ankle was 9° (0° to 15°). Forefoot alignment was neutral in
28 feet (51%) or adducted (<
10°) in 20 feet (36%), >
10° in
seven feet (13%). Hindfoot alignment was neutral or mild valgus
in 26 feet (47%), mild varus (<
10°) in 19 feet (35%), and varus
(>
10°) in ten feet (18%). Heel–toe gait was present in 38 feet
(86%), and 12 (28%) exhibited weight-bearing on the lateral border
(out of a total of 44 feet with gait videos available for analysis).
Overt relapse was identified in nine feet (16%, six children). The
parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive
soft-tissue release or bony procedure, although under-correction
was common, and longer-term follow-up will be required to assess
the outcome. Cite this article:
We investigated whether, in the management of
stable paediatric fractures of the forearm, flexible casts that
can be removed at home are as clinically effective Cite this article:
We undertook a randomised clinical trial to compare
treatment times and failure rates between above- and below-knee
Ponseti casting groups. Eligible children with idiopathic clubfoot,
treated using the Ponseti method, were randomised to either below-
or above-knee plaster of Paris casting. Outcome measures were total
treatment time and the occurrence of failure, defined as two slippages
or a treatment time above eight weeks. A total of 26 children (33 feet) were entered into the trial.
The above-knee group comprised 17 feet in 13 children (ten boys
and three girls, median age 13 days (1 to 40)) and the below-knee
group comprised 16 feet in 13 children (ten boys and three girls,
median age 13 days (5 to 20)). Because of six failures (37.5%) in
the below-knee group, the trial was stopped early for ethical reasons.
The rate of failure was significantly higher in the below-knee group
(p = 0.039). The median treatment times of six weeks in the below-knee
and four weeks in the above-knee group differed significantly (p
= 0.01). This study demonstrates that the use of a below-knee plaster
of Paris cast in conjunction with the Ponseti technique leads to
unacceptably high failure rates and significantly longer treatment
times. Therefore, this technique is not recommended. Cite this article:
Recent reports have suggested an increase in
the number of anterior cruciate ligament (ACL) injuries in children, although
their true incidence is unknown. The prognosis of the ACL-deficient knee in young active individuals
is poor because of secondary meniscal tears, persistent instability
and early-onset osteoarthritis. The aim of surgical reconstruction
is to provide stability while avoiding physeal injury. Techniques
of reconstruction include transphyseal, extraphyseal or partial
physeal sparing procedures. In this paper we review the management of ACL tears in skeletally
immature patients. Cite this article:
We evaluated results at one year after surgical
correction of internal rotation deformities in the shoulders of
270 patients with obstetric brachial plexus palsy. The mean age
at surgery was 6.2 years (0.6 to 35). Two techniques were used:
open subscapularis elongation and latissimus dorsi to infraspinatus
transfer. In addition, open relocation was performed or attempted
in all patients with subluxed or dislocated joints. A mixed effects
model approach was used to evaluate the effects of surgery on internal
and external rotation, abduction, flexion and Mallet score. Independent
factors included operative status (pre- or post-operative), gender,
age, the condition of the joint, and whether or not transfer was
performed. The overall mean improvement in external rotation following
surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and
the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was
a mean decrease in internal rotation of between 27.6° and 34.4°
in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the
normal joint group. Abduction and flexion were unchanged following
surgery. Adding a latissimus dorsi transfer did not result in greater
improvement in the mean external rotation compared with elongation
of the subscapularis alone. Cite this article:
Supracondylar humeral fractures are common in
children, but there are no classification systems or radiological parameters
that predict the likelihood of having to perform an open reduction.
In a retrospective case–control study we evaluated the use of the
medial spike angle and fracture tip–skin distance to predict the
mode of reduction (closed or open) and the operating time in fractures
with posterolateral displacement. A total of 21 patients (4.35%) with
a small medial spike angle (<
45°) were identified from a total
of 494 patients, and 42 patients with a medial spike angle of >
45° were randomly selected as controls. The medial spike group had
significantly smaller fracture tip–skin distances (p <
0.001),
longer operating times (p = 0.004) and more complications (p = 0.033)
than the control group. There was no significant difference in the
mode of reduction and a composite outcome measure. After adjustments
for age and gender, only fracture tip–skin distance remained significantly
associated with the operating time (β = -0.724, p = 0.042) and composite
outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold
for open reduction when treating patients with a small medial spike
angle and a small fracture tip–skin distance. Cite this article:
Fractures of the forearm (radius or ulna or both)
in children have traditionally been immobilised in plaster of Paris (POP)
but synthetic cast materials are becoming more popular. There have
been no randomised studies comparing the efficacy of these two materials.
The aim of this study was to investigate which cast material is
superior for the management of these fractures. We undertook a single-centre
prospective randomised trial involving 199 patients with acute fractures
of the forearm requiring general anaesthesia for reduction. Patients
were randomised by sealed envelope into either a POP or synthetic
group and then underwent routine closed reduction and immobilisation
in a cast. The patients were reviewed at one and six weeks. A satisfaction
questionnaire was completed following the removal of the cast. All
clinical complications were recorded and the cast indices were calculated.
There was an increase in complications in the POP group. These complications
included soft areas of POP requiring revision and loss of reduction
with some requiring re-manipulation. There was an increased mean
padding index in the fractures that lost reduction. Synthetic casts
were preferred by the patients. This study indicates that the clinical outcomes and patient satisfaction
are superior using synthetic casts with no reduction in safety. Cite this article:
The development of tibiofemoral angle in children has shown ethnic
variations. However this data is unavailable for our population. We measured the tibiofemoral angle (TFA) and intercondylar and
intermalleolar distances in 360 children aged between two and 18
years, dividing them into six interrupted age group intervals: two
to three years; five to six years; eight to nine years; 11 to 12
years; 14 to 15Â years; and 17 to 18 years. Each age group comprised
30 boys and 30 girls. Other variables recorded included standing
height, sitting height, weight, thigh length, leg length and length
of the lower limb.Objectives
Methods
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
We compared the accuracy of the growth remaining
method of assessing leg-length discrepancy (LLD) with the straight-line
graph method, the multiplier method and their variants. We retrospectively
reviewed the records of 44 patients treated by percutaneous epiphysiodesis
for LLD. All were followed up until maturity. We used the modified Green–Anderson
growth-remaining method (Method 1) to plan the timing of epiphysiodesis.
Then we presumed that the other four methods described below were
used pre-operatively for calculating the timing of epiphysiodesis. We
then assumed that these four methods were used pre-operatively.
Method 2 was the original Green–Anderson growth-remaining method;
Method 3, Paley’s multiplier method using bone age; Method 4, Paley’s
multiplier method using chronological age; and Method 5, Moseley’s
straight-line graph method. We compared ‘Expected LLD at maturity
with surgery’ with ‘Final LLD at maturity with surgery’ for each
method. Statistical analysis revealed that ‘Expected LLD at maturity
with surgery’ was significantly different from ‘Final LLD at maturity
with surgery’. Method 2 was the most accurate. There was a significant
correlation between ‘Expected LLD at maturity with surgery’ and
‘Final LLD at maturity with surgery’, the greatest correlation being
with Method 2. Generally all the methods generated an overcorrected
value. No method generates the precise ‘Expected LLD at maturity
with surgery’. It is essential that an analysis of the pattern of
growth is taken into account when predicting final LLD. As many
additional data as possible are required. Cite this article:
Permanent growth arrest of the longer bone is
an option in the treatment of minor leg-length discrepancies. The
use of a tension band plating technique to produce a temporary epiphysiodesis
is appealing as it avoids the need for accurate timing of the procedure
in relation to remaining growth. We performed an animal study to
establish if control of growth in a long bone is possible with tension
band plating. Animals (pigs) were randomised to temporary epiphysiodesis
on either the right or left tibia. Implants were removed after ten
weeks. Both tibiae were examined using MRI at baseline, and after
ten and 15 weeks. The median interphyseal distance was significantly shorter
on the treated tibiae after both ten weeks (p = 0.04) and 15 weeks
(p = 0.04). On T1-weighted images the metaphyseal water
content was significantly reduced after ten weeks on the treated
side (p = 0.04) but returned to values comparable with the untreated
side at 15 weeks (p = 0.14). Return of growth was observed in all
animals after removal of implants. Temporary epiphysiodesis can be obtained using tension band plating.
The technique is not yet in common clinical practice but might avoid
the need for the accurate timing of epiphysiodesis. Cite this article:
Most centres in the United Kingdom adopt a selective
screening programme for developmental dysplasia of the hip (DDH)
based on repeated clinical examination and selective ultrasound
examination. The Newborn Infant Physical Examination protocol implemented
in 2008 recommends a first examination at birth and then a second
and final examination at six to ten weeks of age. Due to concerns
over an increase in late presentations we performed a retrospective
review of our 15-year results to establish if late presentation
increases treatment requirements. Of children presenting before
six weeks of age, 84% were treated successfully with abduction bracing,
whereas 86% of children presenting after ten months eventually required
open reduction surgery. This equates to a 12-fold increase in relative
risk of requiring open reduction following late presentation. Increasing
age at presentation was associated with an increase in the number
of surgical procedures, which are inevitably more extensive and complex,
with a consequent increased in cost per patient. The implementation
of an opportunistic examination at three to five months could help
to reduce the unintended consequences of the Newborn Infant Physical Examination
programme. Cite this article:
Symptoms of obstetric brachial plexus injury (OBPI) vary widely
over the course of time and from individual to individual and can
include various degrees of denervation, muscle weakness, contractures,
bone deformities and functional limitations. To date, no universally
accepted overall framework is available to assess the outcome of patients
with OBPI. The objective of this paper is to outline the proposed
process for the development of International Classification of Functioning,
Disability and Health (ICF) Core Sets for patients with an OBPI. The first step is to conduct four preparatory studies to identify
ICF categories important for OBPI: a) a systematic literature review
to identify outcome measures, b) a qualitative study using focus
groups, c) an expert survey and d) a cross-sectional, multicentre
study. A first version of ICF Core Sets will be defined at a consensus
conference, which will integrate the evidence from the preparatory
studies. In a second step, field-testing among patients will validate this
first version of Core Sets for OBPI.Background
Methods
Slipped capital femoral epiphysis (SCFE) is uncommon
in India and we routinely look for associated metabolic or endocrine
abnormalities. In this study we investigated a possible association
between vitamin D deficiency and SCFE. All children presenting with
SCFE during the study period had their 25-hydroxyvitamin D levels
measured as part of an overall metabolic, renal and endocrine status
evaluation, which included measurement of body mass index (BMI).
Vitamin D status was compared with age-, gender- and habitat-matched
controls with acute trauma or sepsis presenting to our emergency
department. A total of 15 children (12 boys and three girls) with a mean
age of 13 years ( Cite this article:
Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18+0–20+6 week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV. The database of the antenatal ultrasound department was interrogated for all suspected cases of CTEV on the 18+0–20+6 week USS, between August 2006 and June 2012. Terminations, stillbirths and outside referrals were excluded. Our Ponseti-service database was searched to identify all patients treated for structural CTEV between January 2007 and November 2012. Cases were excluded if the mother did not receive antenatal-care at our centre. Results from the two searches were cross-referenced, and statistical analysis performed.Aim
Method
Iliopsoas tendinopathy occurs due to friction of the iliopsoas tendon on the iliopectineal bar or the hip capsule causing pain and snapping of the hip. In adolescent cases this condition is generally treated conservatively with physiotherapy, stretching and NSAIDs. Our aim was to study the outcome of non-operative management of iliopsoas tendinopathy. A retrospective 4-year study identified adolescent patients with a clinical diagnosis of psoas tendinopathy managed non-operatively. These patients were followed up by postal questionnaire, which included functional assessment using the Non-Arthritic Hip Score (NAHS). A custom study questionnaire assessed current symptoms and the effects of physiotherapy. All patients not treated conservatively were removed from the study.Aim
Method
The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure. 25 patients (16 boys, 9 girls) who had undergone an IHR using the Ilizarov/TSF construct over a period of 10 years for a variety of pathologies were reviewed.Aim
Method
To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test.Aim
Method
Since 2008 we have been using third generation Fassier Duval (FD) telescopic rods for children with complex and severe osteogenesis imperfecta (sOI). We present our experience with the technique. 8 children with sOI have undergone rodding of 16 lower limb long bones; 6 tibial, 10 femoral. 3 were revision procedures, exchanging previous Sheffield rods that had been implanted with the female portion only. Indications were recurrent fracture and/or progressive deformity. Age range and follow up are 2–12 and 0.4–4.75 years respectively. All but one of the procedures were performed by a single surgeon.Aim
Method
The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups. This was a prospective cohort study of 102 consecutive supine hip arthroscopies in 96 patients (48 adolescent (<18) hips, mean age 13.9 years and 54 adult (>18 hips), mean age 33.8 years) at a tertiary referral paediatric and adult university hospital followed-up for a minimum of two years. Patient demographics, indications for surgery, Modified Harris Hip (MHHS) and Non-Arthritic Hip (NAHS) scores, operative interventions and complications were recorded.Aim
Method
Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, recent evidence suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomitant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. We identified eleven children (13 feet) who had resections of middle facet tarsal coalitions with or without complex foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) for concurrent severe planovalgus between 2003 and 2011. Clinical examination, American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction.Aim
Method
To review the infants in our district general hospital receiving delayed treatment for DDH i.e. those infants who had more than one ultrasound scan prior to diagnosis and treatment. In this group all scans were abnormal at the time of treatment but the scans at first presentation were normal for age when reviewed by our senior radiologist. An audit was performed of all the children attending our institution from 2008–2011 for treatment of DDH following diagnosis with clinical examination and dynamic ultrasound. A senior radiologist and consultant orthopaedic surgeon independently assessed the scans. Two questions were asked (a) were the scans at the time of treatment normal or abnormal and (b) in those who were treated following a repeat scan, was the initial scan normal.Aim
Method
To compare the rate and severity of avascular necrosis following medial open and closed reduction in developmental hip dysplasia and the resulting influence on femoral and acetabular development. The radiographs and hospital records of 118 patients with dislocation of the hip were reviewed. 57 patients (66 hips) underwent medial open reduction and 61 patients (75 hips) underwent closed reduction. Mean follow-up was 10.9 years (5 years to 17.4 years). Avascular necrosis (AVN) was recorded according to the Bucholz and Ogden classification. The acetabular index was measured pre-operatively, at 1 and 4 years following surgery. The final radiograph was assigned a Severin grade. Sharp and centre-edge angles were recorded at final follow-up. A Severin grade I or II was considered a satisfactory result and a grade III to V an unsatisfactory result. Initial non-operative measures, such as Pavlik harness treatment and traction were documented. Additional surgical interventions were noted.Aim
Method
Forearm fractures in children have a tendency
to displace in a cast leading to malunion with reduced functional
and cosmetic results. In order to identify risk factors for displacement,
a total of 247 conservatively treated fractures of the forearm in
246 children with a mean age of 7.3 years ( Fractures of both forearm bones in children have a strong tendency
to displace even in an above-elbow cast. Severe fractures of the
non-dominant arm are at highest risk for displacement. Radiographs
at set times during treatment might identify early displacement,
which should be treated before malunion occurs, especially in older children
with less potential for remodelling. Cite this article:
To inform a working group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), three centres (Bristol, Newcastle and Barts and The London) reviewed the demographics and management of children with SCFE presenting between 2007 and 2012. At all contributing centres with digital PACS records for a minimum of 5 years, a search for the following terms was made of PACS reports: slipped capital femoral epiphysis, slipped upper femoral epiphysis, SCFE and SUFE. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability (Loder criteria), management and complications.Aim
Method
Kite manipulation and casting for congenital talipes equinovarus (CTEV) was noted to require a subsequent posteromedial release (PMR) in almost all of the children treated, with variable outcomes including overcorrection and stiffness. Introduction of the Ponseti serial manipulation and casting technique dramatically reduced the need for PMR. This study assesses the medium term outcomes in these two treatment groups. We retrospectively identified patients treated for idiopathic CTEV between 1997 and 2007 under a single surgeon. Two cohorts with a minimum 4 years' follow-up were treated with Kite (1997–2001) and Ponseti (2002–2007) manipulation and casting. The entire Kite cohort (14 patients) and none of the Ponseti cohort (16 patients) required PMR. All patients were assessed by clinical and functional examination, questionnaire and medical notes review. There was a total of 40 feet (10 bilateral and 20 unilateral) with 20 feet in each cohort.Aim
Methods
With the link between obesity and Slipped Upper Femoral Epiphysis (SUFE) well established and a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the incidence of vitamin D deficiency in SUFE patients and whether low vitamin D levels increases the time to proximal femoral physeal fusion post surgical fixation. All paediatric patients presenting to the orthopaedic department at University Hospital Southampton with a SUFE and tested for vitamin D between June 2007 to present day and who were subsequently found to have low levels of vitamin D, were eligible for inclusion in the study. A deficient level of vitamin D (25-(OH)D) was determined as < 52 nmols/L and insufficiency between 52–72 nmols/L. Levels > 72 nmols/L were considered to be normal. The normal time for 50% of physeal fusion on anteroposterior radiograph quoted in the literature is 9 months.Aim
Method
The objective was to assess whether late presentation of DDH leads to an increase in treatment magnitude and cost. This was a retrospective review of prospectively collected data from our hip instability clinic database. All patients presenting to our hip instability clinic that required any form of treatment for DDH between 1990 and 2005 were included. Children were grouped according to age at presentation and then treatment requirements were reviewed. Average costs were calculated based on procedures performed.Aim
Method
Of 48 consecutive children with Gartland III
supracondylar fractures, 11 (23%) had evidence of vascular injury,
with an absent radial pulse. The hand was pink and warm in eight
and white and cold in the other three patients. They underwent colour-coded
duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate
the patency of the brachial artery and arterial blood flow. In seven
patients with a pink pulseless hand, CCDS showed a displaced, kinked
and spastic brachial artery and a thrombosis was present in the
other. In all cases UV showed reduced blood flow in the hand. In
three patients with a white pulseless hand, scanning demonstrated
a laceration in the brachial artery and/or thrombosis. In all cases,
the fracture was reduced under general anaesthesia and fixed with
Kirschner wires. Of the seven patients with a pink pulseless hand
without thrombosis, the radial pulse returned after reduction in
four cases. The remaining three underwent exploration, along with
the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting
in children in whom the radial pulse remains absent in spite of
good peripheral perfusion should be revisited. Vascular investigation
using these non-invasive techniques that are quick and reliable
is recommended in the management of these patients. Cite this article:
To establish the incidence of clinically significant avascular necrosis (AVN) and the resultant influence on radiological outcome following medial open reduction for DDH. A systematic review of the literature was performed using Medline and Embase, from 1946 to 2012, to identify all relevant clinical studies. We excluded papers with a mean follow-up under 5 years. The effect of length of follow-up, outcome according to Severin, age at surgery, and type of growth disturbance were reviewed.Aim
Method
10 years after the introduction of the Ponseti casting regimen as standard treatment for idiopathic clubfoot at Alder Hey Children's Hospital, we reviewed the mid-term outcomes of the initial 2-year cohort (treated from 2002–2004) 100 feet were treated in 66 patients. 61 of the 100 feet have been prospectively reviewed on an annual/ bi-annual basis since successful correction, with outcomes of the remaining feet obtained by retrospective analysis.Aim
Method
Shelf acetabuloplasty is part of the armamentarium for the treatment of Legg-Perthes-Calve disease. Surgeons have used it to increase the anterolateral cover of the deformed head in advanced stages of the disease. However, others, including the senior author, advocate its use for containment of the diseased femoral head earlier in the disease, for both the prevention of further femoral head extrusion and as an aid in the remodelling process. The current study presents the results of this procedure performed from August 1999 to February 2010. Full sets of x-rays were available for 44 patients (45 hips). Three other bilateral cases were treated with a unilateral shelf.Aim
Method
Differentiation between bone infarction and bone infection in sickle cell disease has traditionally been difficult, even with modern imaging techniques, and widespread antibiotic use is common. Early differentiation between the two conditions would enable more appropriate targeting of radiological investigations, antibiotics and surgery, and avoid un-necessary antibiotic usage. At our tertiary paediatric sickle cell centre, we have developed a sequencing protocol to be able to accurately differentiate between infection and infarction in sickle cell children using Magnetic Resonance (MR) Imaging. We have undertaken a preliminary retrospective study to analyse clinical and laboratory parameters in these children to see whether earlier differentiation prior to MR imaging is possible.Aim
Method
Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome. Since 2010, 38 feet in 31 patients have been treated. Diagnosis of CVT is confirmed with a stress radiograph. The underlying conditions are diverse. The technique involves serial passive stretches and plaster of Paris casts. Once the talo-navicular joint is judged to be reduced, the joint if fixed with a percutaneous pin under local anaesthetic and an Achilles tenotomy performed. Post-operative treatment is as per the Iowa technique with night-time bracing and an AFO for ambulant patients.Aim
Method
At our institution surgical correction of symptomatic
flat foot deformities in children has been guided by a paradigm in
which radiographs and pedobarography are used in the assessment
of outcome following treatment. Retrospective review of children
with symptomatic flat feet who had undergone surgical correction
was performed to assess the outcome and establish the relationship
between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after
correction of soft-tissue contractures and lateral column lengthening,
using standardised radiological and pedobarographic techniques for
which normative data were available. We found significantly improved static segmental alignment of
the foot, significantly improved mediolateral dimension foot loading,
and worsened fore-aft foot loading, following surgical treatment.
Only four significant associations were found between radiological
measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative
finding. Surgeons should be judicious in the magnitude of lengthening
of the plantar flexors that is undertaken and use techniques that
minimise subsequent weakening of this muscle group. Cite this article:
This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score). This was a qualitative patient-centred study at a tertiary paediatric orthopaedic centre involving 50 adolescents aged 13–17 years, composed of five groups of 10 adolescents with slipped capital femoral epiphysis (SCFE), hip dysplasia (DDH), labral tears undergoing arthroscopic treatment, lower limb trauma and a miscellaneous group with conditions including Perthes' disease. A control group of 100 adolescents were also interviewed from a local school. Adolescent and separate concurrent parent groups underwent an ‘open’ phase face-to-face or telephone interview (theme development). This involved agreeing or disagreeing with statements, and open exploration of ideas related to the ‘day in the life’ of an adolescent with hip problems in order to generate and specify themes. This was followed by ranking and finally, scoring and testing.Aim
Methods
We investigated the predictive value of intra-operative
neurophysiological investigations in obstetric brachial plexus injuries.
Between January 2005 and June 2011 a total of 32 infants of 206
referred to our unit underwent exploration of the plexus, including
neurolysis. The findings from intra-operative electromyography,
sensory evoked potentials across the lesion and gross muscular response
to stimulation were evaluated. A total of 22 infants underwent neurolysis
alone and ten had microsurgical reconstruction. Of the former, one
was lost to follow-up, one had glenoplasty and three had subsequent
nerve reconstructions. Of the remaining 17 infants with neurolysis,
13 (76%) achieved a modified Mallet score >
13 at a mean age of
3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder
is a major confounding factor. The positive predictive value and
sensitivity of the intra-operative EMG for C5 were 100% and 85.7%,
respectively, in infants without concurrent shoulder pathology.
The positive and negative predictive values, sensitivity and specificity
of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three
had reconstruction. All of the former and one of the latter achieved
biceps function of Raimondi grade 5. The positive and negative predictive
values, sensitivity and specificity of electromyography for C6 were
65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion.
Neurolysis is preferred for C6 lesions. Cite this article:
Redisplacement is the most common complication
of immobilisation in a cast for the treatment of diaphyseal fractures
of the forearm in children. We have previously shown that the three-point
index (TPI) can accurately predict redisplacement of fractures of
the distal radius. In this prospective study we applied this index
to assessment of diaphyseal fractures of the forearm in children
and compared it with other cast-related indices that might predict
redisplacement. A total of 76 children were included. Their ages,
initial displacement, quality of reduction, site and level of the
fractures and quality of the casting according to the TPI, Canterbury
index and padding index were analysed. Logistic regression analysis
was used to investigate risk factors for redisplacement. A total
of 18 fractures (24%) redisplaced in the cast. A TPI value of >
0.8 was the only significant risk factor for redisplacement (odds
ratio 238.5 (95% confidence interval 7.063 to 8054.86); p <
0.001). The TPI was far superior to other radiological indices, with
a sensitivity of 84% and a specificity of 97% in successfully predicting
redisplacement. We recommend it for routine use in the management
of these fractures in children. Cite this article:
Matrix metalloproteinases (MMPs), responsible
for extracellular matrix remodelling and angiogenesis, might play
a major role in the response of the growth plate to detrimental
loads that lead to overuse injuries in young athletes. In order
to test this hypothesis, human growth plate chondrocytes were subjected
to mechanical forces equal to either physiological loads, near detrimental
or detrimental loads for two hours. In addition, these cells were
exposed to physiological loads for up to 24 hours. Changes in the
expression of MMPs -2, -3 and -13 were investigated. We found that expression of MMPs in cultured human growth plate
chondrocytes increases in a linear manner with increased duration
and intensity of loading. We also showed for the first time that
physiological loads have the same effect on growth plate chondrocytes
over a long period of time as detrimental loads applied for a short
period. These findings confirm the involvement of MMPs in overuse injuries
in children. We suggest that training programmes for immature athletes
should be reconsidered in order to avoid detrimental stresses and
over-expression of MMPs in the growth plate, and especially to avoid
physiological loads becoming detrimental. Cite this article:
McFarland fractures of the medial malleolus in
children, also classified as Salter–Harris Type III and IV fractures,
are associated with a high incidence of premature growth plate arrest.
In order to identify prognostic factors for the development of complications
we reviewed 20 children with a McFarland fracture that was treated
surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven
children (35%) developed premature growth arrest with angular deformity.
The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot
Scale for all patients was 98.3 (87 to 100) and the mean modified
Weber protocol was 1.15 (0 to 5). There was a significant correlation
between initial displacement (p = 0.004) and operative delay (p
= 0.007) with premature growth arrest. Both risk factors act independently
and additively, such that all children with both risk factors developed
premature arrest whereas children with no risk factor did not. We
recommend that fractures of the medial malleolus in children should
be treated by anatomical reduction and screw fixation within one
day of injury. Cite this article:
We present our experience of the modified Dunn
procedure in combination with a Ganz surgical dislocation of the hip
to treat patients with severe slipped capital femoral epiphysis
(SCFE). The aim was to prospectively investigate whether this technique
is safe and reproducible. We assessed the degree of reduction, functional
outcome, rate of complications, radiological changes and range of
movement in the hip. There were 28 patients with a mean follow-up
of 38.6 months (24 to 84). The lateral slip angle was corrected
by a mean of 50.9° (95% confidence interval 44.3 to 57.5). The mean
modified Harris hip score at the final follow-up was 89.1 ( Cite this article:
Although non-union is a devastating and costly consequence of trauma for the child, family and society it is felt to be a rare complication in children. Currently there is no data available in the literature regarding its incidence either per fracture or per head of population. Should we be taking paediatric fracture non-union more seriously regarding research, resource allocation and informed consent? Our aim was to determine the incidence of non-union per child and per fracture. In Scotland Information Services Division (NHS Scotland) records every inpatient admission by ICD-10 diagnosis. As almost all fracture non-unions require intervention ISD provides accurate non-union figures by site and age. However, many fractures are treated as outpatients. Using local data of overall fracture numbers we were able to calculate a ratio of inpatient to total fracture numbers and apply this nationally.Aim
Method
The purpose of this study was to quantify the number of children treated with ESIN (elastic stable intra-medullary nails) at our institution and to determine what proportion of these nails have been removed and the time and difficulty taken to do so. Patients treated with ESIN between 2000 and 2005 were identified by database search. Their notes were reviewed to record patient and initial nailing details, and timing, difficulty and length of metalwork removal procedures. Complications leading to premature removal or following nail extraction were noted.Aim
Methods
To compare the effectiveness of arthrodiastasis with shelf acetabuloplasty for Perthes' disease in older children, by assessing the radiological outcome in matched pairs of children at skeletal maturity. Retrospective observational study case series.Objective
Design